Diagnostic Errors: Assessment, Testing, and Follow-up… Oh My!

1. Diagnostic Errors:Assessment, Testing, and Follow-up…Oh My! Amy Uldrick, MSN, RN, CPHRM Risk Management Consultant, PHT Services, Ltd. Sarah B. Roberts, MPH, CHES, CPHQ, CPHRM, ARM, AIS, AINS Risk Management Analyst, PHT Services, Ltd.

2. The Diagnostic Process • Step 1 – Patient’s Initial Assessment • Step 2 – Having Tests and Getting Results • Step 3 – Follow-up and Coordination of Care

3. Cases with Diagnostic Problems* How many of PHLIPSP’s cases had issues within the diagnostic process? • 13% of professional liability cases • over $4.1 million in reserves and payments *reported between 2008 and 2012

4. Where did the diagnosis-related cases occur?

5. Who was responsible?

6. What happened to the patients?

7. How badly were they injured?

8. What factors contributed to the cases? • Poor Clinical Judgment (95%) • Documentation Problems (26%) • Communication Failures (24%)

9. Within the Diagnostic Process:Cases with Assessment Issues • assessment • 92% of cases • Initial Diagnostic Assessment • Problem Noted, Care Sought • (3% of cases) • 2. History and Physical Conducted • (8% of cases) • 3. Patient Assessed and Symptoms Evaluated • (84% of cases) • 4. Differential Diagnosis Established • (58% of cases) • 5. Diagnostic Test(s) Ordered • (71% of cases) 92% of diagnostic-related cases involve assessment failures.

10. Within the Diagnostic Process:Cases with Assessment Issues Only 6% of cases had an atypical presentation.

11. Within the Diagnostic Process:Cases with Testing and Results Issues 24% of diagnostic-related cases involve testing failures. testing 24% of cases Testing and Results Processing 6. Tests Performed (5% of cases) 7. Test Interpreted (13% of cases) 8. Test Results Transmitted to/Received by Ordering Physician (6% of cases)

12. Within the Diagnostic Process:Cases with Testing and Results Issues Out of the 5 cases where a test result was misinterpreted, Radiology was responsible for 3 of them.

13. Within the Diagnostic Process:Cases with Follow-up Issues follow-up 63% of cases Follow-Up and Coordination 9. Physician Follow-Up with Patient (13% of cases) 10. Referrals/Consults Ordered (42% of cases) 11. Patient Information Communicated Among Care Team (18% of cases) 12. Patient and Providers Establish Follow-Up Plan (6% of cases) 63% of diagnostic-related cases involve follow-up failures.

14. Within the Diagnostic Process:Cases with Follow-up Issues Cardiovascular disease and orthopedic injuries make up 75% of cases where referrals or consults should have been ordered, but weren’t, or where the referral or consult was delayed. • *infection • intestinal disorder • nervous system disorder • other injury

15. Across the Continuum of Care • Overlap in the diagnostic process steps • Occurs throughout the diagnostic process

16. Across the Continuum of Care • Assessment • Physical • Verbal • Listening • Utilizing information • Old records • Test results

17. Across the Continuum of Care • Testing • Ordering • Interpretation • Receiving results

18. Across the Continuum of Care • Follow-up • Handoff • Rechecks • Referrals

19. Across the Continuum of Care • Missed opportunities can lead to catastrophic events

20. Across the Continuum of Care:Case Study Example Failure to follow up on abnormal test results, a lack of communication amongst members of the care team, and incomplete assessment leads to the death of a 73-year-old. A 73-year-old patient with a history of worsening COPD was seen by pulmonology. A chest CT scan was ordered to evaluate his chronic lung disease. The radiologist’s report stated there was a partially imaged fusiform infrarenal abdominal aortic aneurysm measuring 7.3 x 7.1 cm in size, with a large amount of intramural plaque and slash or thrombus, with no suggestion of leakage or rupture. The aneurysm had grown in size since the prior examination (it measured approximately 5.3 x 5.3 cm in size).

21. Across the Continuum of Care:Case Study Example Two days later, a second pulmonologist ordered a chest x-ray due to abdominal aortic aneurysm and syncope. That afternoon the patient presented to his family physician complaining of lower back pain 9/10 and vomiting. Vital signs were temperature 96.3, heart rate 78, respiratory rate 32, and blood pressure 148/82. The physical exam revealed worsening pain with standing and ambulation and prostate tenderness with palpation. The patient was diagnosed with atypical presentation of prostatitis and prescribed ciprofloxacin. Three days later, the patient’s spouse called the on-call physician after-hours stating an increase in back and saddle area pain. The on-call physician suggested pain control with positioning, heat, and over-the-counter medications, and to seek care in the emergency department if symptoms persisted or worsened.

22. Across the Continuum of Care:Case Study Example Four hours later, EMS responded and found the patient thrashing on the ground in severe pain, respiratory distress, and decreasing mental status. Upon arrival to the emergency room, the patient was intubated and a CT scan of the abdomen and pelvis revealed the aneurysm had ruptured. The treating surgeon noted the original finding from seven days prior, and that the patient and family were unaware of the aneurysm. After insertion of an aortic occlusion balloon to seal the aneurysm the patient’s hemodynamic status continued to deteriorate, and he expired.

23. Across the Continuum of Care:Case Study Example This case demonstrates systemic failures in the diagnostic process. First, the abnormal test result was not followed up with timely, and there was no communication to the patient regarding the result. Interaction with the second pulmonologist provided another missed opportunity for follow-up and communication with the patient. The family physician and on-call physician were not able to conduct thorough assessments or differential diagnoses, and therefore intervene, due to not reviewing available records.

24. Putting it all together:Prevention Strategies • Assessment • Be thorough • Old records • Review recent tests • Recognize risks of diagnostic bias • Nursing/EMS hand-off • Multiple visits • Communicate • Care team • Patient • Family

25. Putting it all together:Prevention Strategies • Testing • Scheduling • Logs • Test/tracer • Performance • Logs • Results sent/received • Internal • external • Interpretation • Timely review • Tracking

26. Putting it all together:Prevention Strategies • Follow-up • Consult/referral summaries • Send/receive • Hand-off • POC • Ensure documented well • Patient education • Appointment attempts • Document non-compliance

27. Putting it all together:Prevention Strategies • Test the process • Observe • Tracer • Periodic • Practice Peer Review • Standard of care met? • Learning experiences

28. References • Roberts, S., & Uldrick, A. (Eds). (2014). 2014 Benchmarking Report: Malpractice Risks in the Diagnostic Process. Columbia, SC: PHT Services, Ltd. • Roberts, S., & Uldrick, A. (Eds). (2015). 2015 Benchmarking Report: Malpractice Risks in Communication Errors. Columbia, SC: PHT Services, Ltd. • Hoffman, J. (Ed.). (2014). 2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. Cambridge, MA: CRICO Strategies. • Ruoff, G. (Ed.). (2015). Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Boston, MA: CRICO Strategies.